Usefulness of a novel, slim long syringe-like device for applying surgical mesh through a 5-mm trocar.

We developed a device for introducing surgical mesh through a 5-mm trocar during transabdominal preperitoneal hernia repair. This device is like a slim long syringe; it has a polypropylene outer sheath (outer diameter, 5.8 mm; inner diameter, 5.6 mm; length, 2500 mm) and inner rod, and is made in a similar manner to a drinking straw. Therefore, the manufacturing costs are low. To use the device, folded mesh is placed inside it with a grasper before surgery. The device is then inserted through the trocar, and the mesh is pushed out by the inner rod and applied. The folded mesh extrudes smoothly pubis side to lateral side along the inguinal curve. It reinforces the area without any contamination and expands in a manner that makes it easy for the surgeon to place and fix the mesh. Our device allows mesh to be applied smoothly, comfortably, and economically, and it may reduce the risk of infection.

[A Case of Resected Reactive Lymphoid Hyperplasia of Liver Suspected of Hepatocellular Carcinoma].

A 64-year-old woman who had chronic type C viral hepatitis was referred with a liver tumor detected by magnetic resonance imaging(MRI). She had a history of rheumatoid arthritis which was treated by methotrexate. Ethoxybenzyl-MRI(EOBMRI) showed a low signal in the T1-weighted imaging, a high signal in the T2-weighted imaging and a low signal in the hepatobiliary phase. The tumor was 7 millimeters in diameter at S4, and exhibited enhancement in the arterial phase and wash out in the portal phase by contrast enhanced CT. Imaging findings suggested hepatocellular carcinoma, and we performed partial hepatectomy of S4. Histopathological examination confirmed reactive lymphoid hyperplasia(RLH)of liver. RLH of liver is a rare benign lesion and it is necessary to consider RLH as a differential diagnosis of the liver tumor.

[A Case of an Intraductal Papillary Mucinous Neoplasm Which Rapidly Worsened and Penetrated into the Stomach and the Transverse Colon].

We report a case of a 71-year-old woman.She visited our hospital with a complaint of high fever and abdominal distention. She has been pointed out intraductal papillary mucinous neoplasm(IPMN)4 years ago.Abdominal CT showed cystic legion, 80mm in diameter, on the pancreas.The lesion was unclear at the boundary between the main pancreatic duct and in contact with the stomach, transverse colon.Upper endoscopic and colonoscopic examination revealed the exhaustion image from the intestional tract but not pointed out the malignant findings.We performed total pancreatectomy, total gastrectomy and partial transverse colectomy.Pathological examination revealed the intraductal papillary mucinous carcinoma but the tumor did not invaded the stomach and colon.It is known that some cases of IPMN form fistulae to adjacent organs.We report a case of IPMN penetrating into the stomach and colon.

Impact of nutritional status on outcomes in laparoscopy-assisted gastrectomy.

BACKGROUND: There is a high morbidity rate after digestive surgery in patients with nutritional disorders such as high body mass index and depletion of skeletal muscle. MATERIALS AND METHODS: The ratio of psoas muscle area to trunk area was defined as the Psoas and All trunk Ratio (PandA Ratio) and used as an index of the balance between muscle and adipose tissue. This ratio was determined in 77 patients undergoing laparoscopy-assisted gastrectomy (LAG) for gastric cancer. Patients were classified into groups with and without postoperative complications. Clinicopathological factors were compared between the groups, and relationships of PandA Ratio with other nutritional indices were examined. PandA Ratios were also analyzed in males and females in each Clavien-Dindo grade. RESULTS: Complications developed in 22 patients (28.6%) after LAG. The PandA Ratio was significantly lower in patients with complications in univariate (2.76 ± 0.22% versus 3.66 ± 0.14%, P = 0.0009) and multivariate (P = 0.0064) analyses. A low PandA Ratio was also associated with more severe complications in males. CONCLUSIONS: Measurement of the areas of the psoas muscle and trunk on CT is useful for evaluation of the balance between skeletal and adipose tissue. The PandA Ratio derived from these measurements is a predictor of the clinical course after LAG in males.

A novel procedure for introducing large sheet-type surgical material with a self-expanding origami structure using a slim trocar (chevron pleats procedure).

BACKGROUND: Large sheet-type surgical materials (e.g., absorbable hemostat, adhesion barrier membranes, and flat surgical mesh) are difficult to introduce into a corporeal cavity using a 5-mm trocar; however, laparoscopic surgeries that use mainly 5-mm trocars are increasing. Furthermore, it is necessary not only to introduce but also to secure the applied surgical material and expand it from the original surgical site. To address these challenges, we developed a novel procedure for introducing such surgical materials into a corporeal cavity using a 5-mm trocar and a self-expanding origami structure, called the "chevron pleats procedure (CPP)". METHODS: We used CPP in 114 cases of laparoscopic surgery for gastrointestinal diseases. The chevron folding pattern is an excellent origami structure and compactly folds a large sheet of material for use with a slim trocar. Surgical materials were folded using a chevron pleats pattern and inserted into a novel, slim, long syringe-type device, which was made from a specially ordered precision polypropylene tube, for introduction into a corporeal cavity. When the surgical material was used, the end of the device was placed above the surgical site and the inner rod was pushed. The surgical material was securely injected and expanded over the surgical site. RESULTS: Surgical materials were introduced smoothly and securely using a 5-mm trocar to a site of intraoperative bleeding, the incisional surface of the liver, and defects of the abdominal wall or peritoneum. Efficient hemostasis was attained, the introduction and expansion of surgical mesh was made simpler, and the covering of defects of the peritoneum with adhesion barrier membranes, which is typically difficult during laparoscopic surgery, was easily performed. CONCLUSIONS: CPP is a basic utility procedure for introducing several sheet-type surgical materials into a corporeal cavity with a 5-mm trocar and might help ensure efficient and safe laparoscopic surgery.

[Solitary Splenic Hilar Nodes Metastasis from Ovarian Cancer Managed by Splenectomy with Pancreas Tail].

Solitary splenic metastasis from cancer is known as a rare disorder in cancer patients. In the present study, we report our experience regarding pathophysiology and treatment tactics of the splenic metastasis caused by ovarian cancer after perioperative chemotherapy. A 50s female presented to our clinic complaining of growing solitary splenic hilar node in CT. Hysterectomy, bilateral oophorectomy, omentectomy and adjuvant therapy was performed after neoadjuvant therapy with TC regimen. Five years and 3 months after surgery, she presented growing solitary splenic hilar nodule in CT. After staging laparoscopy, this lesion is judged to be able to be resected absolutely. Splenectomy and pancreas tail resection was performed. She has survived 39 months after 2nd surgery without recurrence. She recieved a diagnosis of solitary splenic metastasis from past ovarian cancer with whitch pattern of immunostaining was accord closely. Therapeutic tactics for solitary splenic metastasis is splenectomy because of the prognosis after complete resection is thought to be well.

Prognostic Impact of a Nutritional Index Including Muscle Volume in Stage 4 Colorectal Cancer.

BACKGROUND: Nutritional status influences cancer prognosis. Measurement of the area of the psoas muscle on computed tomography is useful for evaluation of skeletal muscle mass and prediction of prognosis. PATIENTS AND METHODS: The psoas muscle index (PMI) was determined in 42 patients undergoing surgery for stage 4 colorectal cancer. Patients were classified into high and low PMI groups using a cutoff of 5.5×10-4 cm2 m-2 Relationships of PMI with prognosis, chemotherapy period, and postoperative complications were examined. RESULTS: The 3-year overall survival rate was 24.0%. PMI was significantly associated with 3-year OS in univariate (high vs. low PMI: 43.0% vs. 12.9%, p=0.0415) and multivariate (p=0.0146) analyses. A low PMI was associated with a shorter period of chemotherapy. A reduction in PMI was a predictor of a poor prognosis. CONCLUSION: PMI status is related to the period of chemotherapy and is an independent prognostic factor in patients with stage 4 colorectal cancer.

[A Case of Peritoneal Dissemination of Hilar Cholangiocarcinoma Presenting with Hematuria Six Years after Radical Surgery].

A 76-year-old man underwent radical surgery for Stage IV a hilar cholangiocarcinoma in July 2009, and had been followed at an outpatient clinic. Although no apparent recurrent lesion was detected by PET/CT examination, an elevated CA19-9 level was found in January 2014. He was then started on the oral anticancer drug S-1. However, his CA19-9 level increased gradually. The patient presented to a urological department with a complaint of macrohematuria in May 2015. Detailed examination revealed a mass lesion at the top of the urinary bladder, which was suspected to be peritoneal dissemination of the known hilar cholangiocarcinoma invading the urinary bladder wall. Thus, he underwent partial resection of the urinary bladder in July 2015. A histopathological examination of the resected specimen confirmed the diagnosis of recurrence. The patient is nowreceiving chemotherapy with gemcitabine and cisplatin. Detection of recurrences of cholangiocarcinoma is often difficult since the recurrence pattern of cholangiocarcinoma varies widely. However, early detection might enable longterm survival by adequate treatment including chemotherapy. Therefore, thorough multidisciplinary examinations are required when recurrence of cholangiocarcinoma is suspected. In addition, long-term follow-up after radical surgery is required since cholangiocarcinoma sometimes shows slow progression.

[A Case of Trousseau's Syndrome Caused by CA19-9-Producing Gastric Cancer].

Trousseau's syndrome is a coagulation disorder occurring in cancer patients. In the present study, we report our experience regarding the pathophysiology and treatment strategies of this syndrome that is caused by CA19-9-producing gastric cancer during long term chemotherapy. A 60s male presented to our clinic; he was found to have a high level of CA19-9. An advanced gastric cancer was identified by gastric scope. A totalgastrectomy was performed. Severalcourses of chemotherapy were administered, and the level of CA19-9 was measured over a long period. Three years and 2 months after the surgery, he presented to the emergency room complaining of acute onset of aphasia and paresis of the extremities. Brain MRI showed multiple cerebral infarctions. He was diagnosed with Trousseau's syndrome. Although decision making is difficult in the treatment of this syndrome, owing to the complex medicalhistory associated with it, it is essentialthat strategies be established for achieving successfultreatment results in the future.

[A Case Report of Reoperation for Intractable Obstruction of the Stomach after Surgery for Esophageal Cancer].

Although esophageal reconstruction using the stomach is common in surgery for esophageal cancer, this procedure sometimes results in delayed gastric emptying and reflux. This is a case report of reoperation for intractable obstruction of the stomach after initial esophageal surgery in a 59-year-old man. The obstruction was resistant to conservative management. We resected the duodenum, preserving the vascular pedicle of the right gastroepiploic vessels, and performed reconstruction with a Roux-en-Y procedure in the second operation. There was marked improvement in gastric emptying.

Efficacy of transumbilical laparoscopic-assisted appendectomy for appendicitis: a four-year experience at a single center.

PURPOSE: To compare the surgical outcomes after transumbilical laparoscopic-assisted appendectomy (TULAA) and open appendectomy (OA) at a single institution. METHODS: We compared the surgical outcomes for 94 consecutive patients who underwent TULAA between April 2010 and March 2014 to those for 91 consecutive patients who underwent OA between April 2006 and March 2010. RESULTS: There were no significant differences in the clinicopathological backgrounds between the two groups. Although the lengths of the operations were similar in both groups, the postoperative hospital stay was significantly shorter in the TULAA group (4.7 days vs. 5.4 days, P = 0.02). The need for abdominal drain insertion was significantly reduced in the TULAA group owing to sufficient intraperitoneal exploration (P = 0.03). The incidence of postoperative complications was also lower in the TULAA group, but the difference was not significant (8.6 % vs. 12.1 %, P = 0.31). In complicated cases, a lower incidence of surgical site infection was confirmed in the TULAA group (6.7 % vs. 20.7 %, P = 0.12). CONCLUSION: Our results demonstrated that TULAA provided better surgical outcomes, especially a faster recovery. TULAA could be an effective procedure incorporating both open and laparoscopic techniques, and can be implemented as a standard procedure for the treatment of appendicitis, regardless of disease severity.

[Combination of self-expandable metallic stent insertion and laparoscopic surgery as a less invasive treatment of obstructive left-sided colon cancer].

The purpose of this study was to evaluate the outcome of treating obstructive left-sided colon cancer with a combination of self-expandable metallic stent (SEMS) insertion and laparoscopic surgery. Ten patients were included in this study. Two patients had obstructive transverse colon cancer, and eight had obstructive sigmoid colon cancer. The patients had a SEMS inserted preoperatively as a bridge to surgery. Efficient decompression was achieved in all the patients, without any complications. Normal oral intake was possible until the laparoscopic, or laparoscope-assisted, one-stage radical operation. The SEMS insertion did not affect the surgical maneuver or laparoscopic operation at all. None of the patients developed any postoperative complications. After surgery, five patients were diagnosed with Stage II disease and three patients were diagnosed with Stage IIIA disease. The remaining two patients had distant metastasis (para-aortic lymph node and liver) and were diagnosed with Stage IV disease. Chemotherapy was administered to the two patients with Stage IV disease after a comparatively early recovery from a less invasive surgical procedure. SEMS insertion appears to be an effective, less invasive decompression method. When used in combination with laparoscopic surgery, SEMS insertion appears to be a safe and less invasive method of treating obstructive left-sided colon cancer.

[A case report of distal gastrectomy with thrombectomy after NAC for Gastric cancer].

This is a case report of gastric cancer with a tumor embolus in the portal vein of a 76-year-old male. Both computed tomography (CT) and upper gastrointestinal endoscopy were performed. The diagnosis was gastric cancer with an accompanying tumor embolus in the portal vein, specifically in the superior mesenteric vein. After neoadjuvant chemotherapy, a distal gastrectomy, and thrombectomy were performed. Upon pathological examination, the main tumor was diagnosed as adenocarcinoma, and the embolus was confirmed to extend from the main tumor into the superior mesenteric vein. Upon immunostaining examination, neither the embolus nor main tumor expressed alpha-fetoprotein (AFP), but both expressed carcinoembryonic antigen (CEA). Gastric cancer with a tumor embolus in the portal vein is considered an incurable disease. However, with no other non-curative factor than portal vein embolus, it is possible that gastrectomy with thrombectomy can result in a good prognosis. On the other hand, it is extremely difficult to improve the prognosis of gastric cancer with both tumor embolus in the portal vein and liver metastasis.

Efficacy of the modified anvil grasper for laparoscopic intra-corporeal circular stapled anastomosis.

The traditional anvil grasper may be difficult to use for connecting the stem of an anvil with the centre rod of a circular stapler because the grasper holds the anvil completely still. In addition, the head angle is fixed and cannot handle the anvil head delicately in a tight pelvic space. Many surgeons use a grasper designed for holding the bowel or a dissector for holding the anvil during intra-corporeal circular stapled anastomosis during low anterior resection, sigmoidectomy, left hemi colectomy and know that it is difficult to connect segments with these instruments due to slipping. A new modified anvil grasper was developed with curved blades that can easily grasp the stem of an anvil and smoothly connect it with the centre rod of the circular stapler. This grasper should be useful for surgeons performing laparoscopic intra-corporeal circular stapled anastomoses, which are the most challenging part of laparoscopic colorectal surgery.

Usefulness of the novel evolutional anvil grasper for laparoendoscopic surgery for intracorporeal circular stapled anastomosis during laparoscopic colorectal surgery.

Traditional anvil graspers cannot delicately handle the anvil head as a result of their unique jaw shape that enhances grip force, and they are not suitable for confined pelvic space. With a manufacturing company, we developed a novel anvil grasper, the evolutional anvil grasper for laparoendoscopic surgery (EAGLE), to ensure more precise and safer anastomosis procedures. The EAGLE has curved blades that create a 6-mm grasping surface that is the same diameter as the anvil stem and is covered with tungsten carbide tips. When using the EAGLE, a surgeon grasps the anvil stem slightly and easily, handles the anvil head and proximal colon, and smoothly sets the anvil to the center rod of the circular stapler. A surgeon can also securely grasp the stem of the anvil, push it into the center rod of the circular stapler and then perform a sequence of actions in anastomosis procedures smoothly and safely.

A novel procedure for introducing a large gauze into the corporeal cavity by using a slim trocar (the Tornado gauze procedure).

INTRODUCTION: When a large gauze is needed during a single-incision surgery or reduced port surgery using slim (5-mm) trocars, the operation needs to be interrupted to introduce the gauze via an incision or to change to a large trocar. We describe here a novel procedure for introducing a large gauze into the corporeal cavity by using a slim trocar, called the "Tornado gauze procedure" (TGP). MATERIALS AND METHODS: Commercially packed Trox(®) (Osaki Medical, Nagoya, Japan) gauze (30×150 mm, 4-ply) and a specially ordered precision stainless steel tube (Smart introducer; Kinugawa Factory, Kyoto, Japan) are used for the TGP. The gauze is screwed into the Smart introducer. When the surgeon needs a gauze, a Smart introducer with a gauze is set into the 5-mm trocar; then, the 5-mm grasper is used to push the gauze into the corporeal cavity with small screwing-in movements. The gauze is also gently removed from the corporeal cavity through a 5-mm trocar. RESULTS: This procedure efficiently and safely introduced the gauze for hemostasis, blunt dissection, suction filtering, and organ retraction without interrupting the pneumoperitoneum to introduce the gauze in single-incision laparoscopic cholecystectomy, transabdominal preperitoneal hernia repairs, and appendectomy, with good visualization and adequate working space. The rhythm of surgery remains undisturbed with the use of the TGP, even in a high-risk and high-stress situation. The port's valves were not disabled during surgery, and no procedure-related complications were reported. CONCLUSIONS: TGP is expected to be helpful to surgeons and enhance the safety of laparoscopic surgeries involving the use of slim trocars.

[Radiofrequency ablation therapy for a pelvic recurrence from rectal cancer after radiotherapy in patient on maintenance hemodialysis-a case report].

A 75-year-old man, who was on maintenance hemodialysis, underwent a radiotherapy for locally recurrence of rectal cancer. A pain palliation was achieved and serum tumor markers were reduced. However, after six months, a tumor re- growth was detected and sacral pain was increased. Then, a radiofrequency ablation (RFA) was performed repeatedly as a palliative therapy and pain palliation was achieved. RFA is a safe and effective palliative therapy for patients of poor-risk, such as a terminal stage or hemodialysis patient. Furthermore, it is able to perform repeatedly when the response was not satisfactory. However, a Cool-tip electrode could not to be placed because tumors were hardened by radiotherapy and a repeat of RFA. Then a development of novel Cool-tip electrode may be needed.

[A case of metastatic bladder cancer occurring after surgery for differentiated gastric cancer controlled by combination therapy of paclitaxel/S-1].

A 70-year-old male visited the hospital with a complaint of stomachache. Hydronephrosis was observed in the right kidney, and further examination confirmed a diagnosis of metastatic cancer limited to the bladder and rectovesical pouch after surgery for differentiated gastric cancer. Chemotherapy using paclitaxel(PTX)/S-1 was initiated. One course included 14 days of administration of S-1 (100 mg/body) followed by a 7-day interval, and the administration of PTX (60 mg/body) on the 1st and 15th days. General malaise developed after 4 courses, the dose of S-1 was reduced (80 mg/body), and PTX was administered only on the 1st day. CT conducted 9 months after the start of chemotherapy revealed the disappearance of ascites, decreased thickness of the bladder wall, and reduced size of the tumor in the rectovesical pouch. No new distal metastasis or peritoneal metastatic nodule has been observed, and there has been no tendency toward exacerbation for one year after the initial diagnosis. PTX/S-1 was suggested to be an effective treatment for metastatic cancer limited to the bladder and rectovesical pouch after surgery for differentiated gastric cancer.

[Long-term disease-free survival following multimodal treatment in a patient with curatively unresectable advanced gastric cancer with metachronous liver metastasis].

A case was a 57-year-old man. Despite a diagnosis of cStage IV gastric cancer (cN2, cH0, cM0, cT3 (SE), cP1), we preferentially performed a non-curative surgery to avoid stenosis or bleeding by tumor invasion. Since no evidence of peritoneal metastasis was found at surgery, distal gastrectomy with D2 lymph node dissection was performed, and lymph nodes anterior to the pancreatic head were sampled. The pathological diagnosis was pT3 (SE), pN2, sH0, pM1 (LYM), pStage IV. After the surgery, S-1 was administered. One year and 9 months later, a solitary metastasis was found in S6 of the liver, and the patient underwent radiofrequency ablation (RFA) followed by adjuvant S-1. Currently, 5 years and 10 months after the surgery, the patient is under follow-up, and remains alive with recurrence-free. We speculate that in the presence of N or M (LYM) factors for stage IV gastric cancer, surgery with lymphadenectomy, which does not prevent the completion of adjuvant chemotherapy, followed by multimodal treatments such as continued chemotherapy and RFA, led to the long-term survival.

[A patient with metachronous ovarian metastases of signet-ring cell carcinoma of the transverse colon showing long-term survival after surgery].

The patient was a 43-year-old female who consulted a local physician due primarily to lower abdominal pain. She was referred to our hospital for close evaluation and treatment. Since circumferential cancer was detected in the transverse colon by lower digestive tract endoscopy, the patient was hospitalized for surgical treatment. Transverse colectomy (Cur A) was performed, histopathological examination indicated signet-ring cell carcinoma of the transverse colon, and the lesion was diagnosed as type 4, SS, ly3, v0, n1 (+), Stage III a. Postoperative adjuvant chemotherapy was recommended, but the patient was psychologically unstable and strongly rejected chemotherapy. The patient was periodically followed-up after surgery, but a mass was detected in the left ovary by CT after 1 year and 6 months, and bilateral ovariectomy was performed with a diagnosis of ovarian metastasis. The histopathological diagnosis was signet-ring cell carcinoma, and the ovarian lesions were judged to be metastases of the transverse colon carcinoma. Since the patient did not consent to postoperative chemotherapy, as after the initial surgery, she was followed-up without treatment. She was admitted with ileus due to peritoneal metastasis 4 years and 10 months after the initial surgery, and, despite of the surgery, she died due to carcinoma 5 years after the initial surgery.